Pregnancy Massage

Name:

Date:

Delivery Due Date:

Name of Obstetrician/Midwife?

Have you had any complications or abnormalities?

If yes, please describe:

If yes, do you have the approval of your midwife or physician to receive massage?

Please list any of the above below.

Have you eaten within the last 3 hours?

Are you experiencing any tension or soreness in your muscles at this time?

If yes, please describe:

Are you sensitive to any scents or smells?

Would you like to have your abdomen massaged?

Is there anything else you would like to discuss about your pregnancy?